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ONSITE WAS, WATER TREATMENT SYS'. M PERMIT SCANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBERA E -3—FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Gfr� y <br /> JOB ADDRESS �J L (i CITY/ZIP 51-7e-7C <br /> CROSSSTREETyy Z� APN /�I PARCEL SIZE n / p <br /> OWNERNAME �4, �� ,�&,,J LIQ.✓ PHONE- <br /> OWNER ADDRESS L 'Tr rNC .L� CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS N/ CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER IF NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPAIR/ADDITIONNLlENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ..-Z'. ESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> �, �NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> .!d/LSEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION It PROPERTY LME it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION R PROPERTY LINE It <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LME ft <br /> ❑ MOUNDED WIDTH it LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS AFRLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> CES,STATE VS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> I IU 2 OURAD A NOTICE REQUIRED FOR INSPECTIONS-PLE � J -7697 <br /> ,eZ% <br /> SIGNED TITLE <br /> DATE d <br /> 953 <br /> '}rl <br /> 1 <br /> tit <br /> 4 <br /> i14 � t <br /> r -r 1 <br /> L rtIT n <br /> i 7 r <br /> NIR N E <br /> t k.-' A L H F .:1 <br /> gNl <br /> _.DEPA�NiEINTU, i/N%V-/ <br /> Application Accepted By ate e�rrrr' a Area Employee ID# <br /> Final Inspection B ate O ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> C1 11) <br /> lE <br /> PE SC Received Chec Amount Date Permit/ Invoice III Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 0 ' S <br /> 7 Z <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 17/1212003 <br />